The incidence of
medical mistakes in primary care is not rare and the probability of
faults producing grave detriment is great. Medical negligence is a
‘tort’, or ‘civil wrong’. It is a ‘wrong’ resulting from a doctor's
carelessness. Simply put, negligence means failing to do something that
should have been done as defined by current medical practice or doing
something that a physician with a duty to care for the patient should
not have done. Whereas about one percent of hospital admissions
result in an adversative event due to negligence, faults are probably
much more common, because these studies detect only errors that led to
assessable adversative events occurring soon after the mistakes.
Moreover, though after heart disease and cancer, medical mistake is the
3rd important reason of death in the USA, maybe the real problem in
medical faults is not bad persons in health care; rather it is that
good individuals are working in corrupt systems. Poor communiqué ,
blurred lines of power of doctors, nurses, and other care providers,
incoherent recording systems, differences in healthcare provider
teaching and practice , failure to recognize the frequency and
significance of medical mistakes, overestimation of
insufficient data, sleep deficiency and night shifts,
doctor’s depression, fatigue, and burnout , unfamiliar settings,
diverse patients, and time pressures have been accounted as vital
causes of medical error. In the following article, some proven
neurologic cases, which have been diagnosed in the beginning by at
least one neurologist as conversion disorder and referred to
psychiatric facilities, have been described. This article tries to give
the reader an awareness regarding the aforesaid dilemma, in the ground
of psychological medicine.

Introduction:

Background:

According to data, the quantity of deceases in United States hospitals,
which are supposedly as a result of medical faults, is ominously high. While
according to a recent report, medical errors kill yearly between 44 000
and 98 000 individuals in United States hospitals (1), this bulk of
information have facilitated creating strategies for providing patient safety
throughout the country. The current data
indicates that medical mistakes kill yearly around 180 000 individuals in
hospitals and medical faults may be the fifth foremost reason of death in
the United States of America. If these implications are exact, the present
health care system can be accounted, as well, as a community health threat (1),
and the existing scheme of medical
negligence or misconduct does a poor job as regards the wellbeing of
patients. Societal and economic powers are changing
the structure of health care from the individual doctor to a union of health
care specialists, categorized by liable medical groups (2).

In general, more doctors
are working, outcomes and qualities are regularly assessed, and new
financial
policies are planned. In the same way,
medical mismanagement necessities
transition to a different pattern that is compatible with the
contemporary period
of medical care. Cooperative liability, the impression that patient
care is the
duty of all the associates of the health care society,
obliges misconduct modification
that mirrors organizational-based style of practice of medicine. On the
other
hand, enterprise accountability, joined with medical slip
communication and corrective platforms, delivers the lawful agenda
essential
for the ‘patient-centered’ practice of medicine in current
situation (3).The word ‘error’ in
medicine is utilized as a term for approximately all of the
complications hurting
the patients. Also, medical mistakes are often designated as human
faults in healthcare(4). Whether this label is ‘human error’
or ‘medical
error’, one description used for it in medicine pronounces that it
happens when
a healthcare worker selects an unfortunate
mode of care or incorrectly performs a proper technique of care. Anyway, a medical
fault is an avoidable adversative consequence of care, whether or not
it is hurtful or manifest to the patient. This might contain an erroneous or imperfect
management or diagnosis of a behavior, syndrome, disease, infection, damage, or other illness .

According
to a national survey
in United Kingdom, each year, medical errors costing in excess of two
billion
ponds (5). Another study has found that drug mistakes are among the
most common medical errors, hurting as a minimum 1.5 million
individuals each
year. Likewise, medical faults, globally, affect at least one in ten
patients (6). According to the findings of a new study, after heart
disease and cancer, medical mistake is the 3rd important reason of
death in the USA. It deserves to be mentioned
that The Institute of Medicine (IOM) released "To Err is
Human," in 2000, which stated that the real problem in medical faults is
not bad persons in health care—it is that good individuals are working in corrupt
systems that should be prepared safer (6). Moreover,
poor communiqué and blurred lines of power of doctors, nurses, and other care
providers are among the causative issues (6). Incoherent recording systems in a hospital may cause
disjointed systems in which frequent hand-offs of patients ends in lack of harmonization
and mistakes (6). Differences in healthcare
provider teaching & practice and
failure to recognize the frequency and significance of medical mistakes as well
intensify the threat (7, 8). Then again,
the supposed ‘July effect’ happens when firsthand
residents come to training hospitals and instigating an upsurge in medication mistakes
(9, 10).

Cognitive mistakes usually come across in
medicine were originally identified by psychologists Amos Tversky and Daniel
Kahneman in the early 1970s. Jerome
Groopman, author of ‘How Doctors
Think’, has assumed that these are ‘cognitive pitfalls’, or biases which can cloud
our judgment. For instance, a physician may overestimate the first data run
into his head, influencing his decision. Another drawback is where stereotypical
presumptions may skew intelligence (11).

Sleep deficiency has also been mentioned
as a causal reason in medical mistakes (11). According to a study,
being awake for above twenty four hours could cause medical
interns to ‘double’ or ‘triple’ the number of avoidable medical faults, involving
those that had caused harm or decease (11). Similarly, night shifts are connected
with poorer surgeon performance through laparoscopic surgeries (11). Doctor’s
risk factors consist of depression, fatigue, and
burnout (12). Issues related to the clinical setting, too, include
unfamiliar settings, diverse patients, and time pressures (11). All
of the following case examples, which have been chosen in this regard, have
been diagnosed primarily and unreasonably, by at least one neurologist as
conversion disorder and referred to psychiatric facilities. This article tries
to give the reader awareness about the aforesaid dilemma, in the ground of
psychological medicine. Names, dates and locations have been omitted totally to
keep the confidentiality of the cases.

Case
1.

A
42 years old male driver had been referred by his general physician to a
neurological clinic after observing some tremors in the upper limbs of the
patient. The patient had been visited due to sleep problems and nervousness.
According to the patient, his problems had been started a few weeks after his
divorce from his wife, which had been occurred one year earlier due to various financial
and family problems. The care of children also had been transported to him.
While the primary prescription of fluoxetine, 20-40 milligram per day, could
only mitigate some of the psychological symptoms like anxiety and dysphoria,
the aforesaid tremor got worse, which had not respond to 30 milligram
propranolol per day, too. So he had been referred to a neurologist for further analysis.
After primary checkup and based on the personal and family history, since no
specific finding was evident at clinical exam, he had been prescribed a series of
drugs, in accompany with the aforesaid fluoxetine, like Primidone, 500
milligram per day and Trihexyphenidyl 6 milligram per day, with the primary
diagnosis of essential familial tremor, which could be aggravated, too, by
means of psychological stresses and maybe small amounts of antipsychotis ( Perphenazine,
4-8 milligram per day which had been prescribed by the GP due to his
aggressiveness).

After another six months, due to intensification of tremor that
had interfered with some of his daily activities, and also his anxiousness he had
been referred to a consultant psychiatrist. In the initial examination, in
addition to a relatively fluctuating tremor, between fine and course, depending
on the situation of the limbs, some mild rigidity as well was palpable in the
proximal muscles of the upper limb, without any evident cogwheel or clasp-knife
rigidity. Due to lack of obvious concern
in him regarding his earlier divorce or similar worries, absence of strong or
insistent relationship between tremor and psychosocial stresses, unexplained
mild rigidity of the proximal muscles of the upper limbs in spite of
discontinuation of antipsychotic, and no satisfactory response to the
abovementioned medications, so he was referred again for another neurologic
evaluation. This time, due to low serum ceruloplasmin level (17 mg/dl), low
serum copper ( 55 microgram/dl), and increased urinary copper excretion ( 150
microgramm Cu in 24 h) , presence of copper
deposition in Descemet's membrane (Kayser-Fleischer rings) in slit-lamp
examination, and slightly enlarged lateral and third ventricles, widened
cerebral and cerebellar sulci, and hypodensity of posterior parts of lenticular
nuclei in CT Scan , plus bilateral,
symmetrical signal hyperintensities in the Basal ganglia, Midbrain, Pons, and Thalamus
in T2-weighted MRI, the diagnosis of Wilson's disease (Hepatolenticular
Degeneration) had been suggested for him and thus transferred to a neurologic
clinic for further investigation and management.

Case
2.

A 38 years old
man had been hospitalized in the psychiatric ward due to aggressiveness,
suspiciousness, disturbed sleep and some movement problems. When he was 18 year
old, he had been diagnosed as a case of bipolar I disorder due to similar
profile of symptoms, except than movement problems, which had been started since
two years ago. During the last two decades a number of neuroleptics, mainly
first generation antipsychotics, mood stabilizers like lithium and valproate,
and benzodiazepines had been prescribed for him. One year ago he was
hospitalized again in another psychiatric hospital for his increasing movement
problems, which had been assigned to his antipsychotic medications, and had
been treated by dopaminergic drugs like Levodopa - Carbidopa (Sinemet)
(750-1000 milligram per day), Amantadine (200 milligram per day), and also
Trihexyphenydil (6 milligram per day). The aforesaid problem had been diagnosed
as medication induced movement disorder (pseudo-parkinsonism) by a consultant
neurologist . But there was lack of effectiveness and worsening of the problem.
After the recent admission and disregard to the past and present psychiatric
history of anxiety, depression, impulsiveness, dis-inhibition, suspiciousness
or paranoid delusions, in the clinical examination a mild-moderate fluctuating
rigidity and tremor in the upper and lower limbs was evident, which had made clumsiness
and unsteady gait, respectively. Also,
there were some problems regarding swallowing solid foods and talking fluently.
Also, a fixed stare with a smiling expression and drooling was evident. So,
another neurologic consultation had been requested by his psychiatrist; this
time also, the antipsychotic induced movement disorder had been confirmed, once
more, by the second consultant neurologist, who, moreover, proposed tardive Parkinsonism
as a probable differential diagnosis.

Due to lack of effectiveness of the
aforesaid treatments, in spite of discontinuation of prescribed antipsychotic
(Quetiapine 75 milligram per day), Electroconvulsive therapy (ECT) was started,
which stopped after five sessions, due to existence of mild fever and lack of
significant effect. Nonetheless, due to refractoriness of the movement symptoms
against the recommended treatments, their fluctuating course and persistence in spite of discontinuation
of neuroleptics, atypical emergence and persistence of the primary
psychopathology, and a long gap ( 18 years) between the first prescription of
neuroleptics and subsequent emergence of movement symptoms, an additional
neurologic consultation had been requested for the patient. This time, a suspicious
serum ceruloplasmin level (23 mg/dl), low serum copper (76 microgram/dl), and
increased urinary copper excretion (153 microgramm Cu in 24 h) had been found. MRI
scan, too, had showed decreased signal intensity (hypodensity) in the Striatum
and superior Colliculi and increased signal intensity in the Midbrain Tegmentum
(except for red nucleus) and in the lateral Substantia Nigra ( reticular zone).
So, diagnosis of Wilson's disease (Hepatolenticular Degeneration) had been
suggested for him and transferred to a neurologic facility for further
investigation and management.

Case
3.

A forty seven
years old father with a at least five percent weight loss in the last year, in
spite or normal appetite and sleep, had been examined by an internist, but the
primary laboratory examinations and clinical checkups, including thyroid
analyses and computed tomographic scan (CTS), had not proved any specific
medical diagnosis. So due to slight restlessness, increasing feeling of tiredness
and loss of energy in comparison with before, nervousness, irritability and
decrease in attentiveness had been referred to a psychiatrist for analysis regarding
psychological problems. In the mental state examination, and in addition to the
abovementioned complaints, a slight forgetfulness, disturbance in
concentration, negative thoughts, minor disturbance of conduct, history of
enuresis during childhood, and a past history of mixed anxiety and depressive
disorder after his father’s death, were as well detected, which in sum
concluded to a diagnosis of mild to moderate major depressive disorder for the
present episode of illness. But the primary medicinal management with
fluoxetine, 20 – 60 mg per day in a two months period, was not effective. So
after a consultation with an associate neurologist and based on newly detected
anomia, verbal perseveration, small time disorientation, trivial mood swings,
score of 17 in Mini Metal State Examination (MMSE), and history of some head traumas
with decrease of consciousness in the past, the diagnosis turned to pre-senile
dementia and the aforesaid psychiatric complaints had been classified as
secondary symptoms due to that. So treatment with Rivastigmine, 3-6 mg per day,
in addition to fluoxetine, started. But ineffective outcomes after another two
months and the progressive course of the ailment resulted in an additional
consultation with another teammate neurologist. After a new clinical inspection
and detection of trivial fasciculation in upper limbs, muscle atrophy and
weakness in upper extremities in Electromyogram (EMG), and atrophy of the
frontal and/or temporal lobes in Magnetic Resonance Imaging (MRI), the
diagnosis turned to Fronto-Temporal Degeneration (FTD) with motor neuron disease
(FTD/MND) , and the patient transferred to a neurologic facility .

Case
4.

A
23 years old man had been hospitalized due to restlessness, aggressiveness,
decreased sleep, increased libido, delusion of grandeur, and obsession. The incessant
and fluctuating course of the problems had been started from around four years
ago with a series of psychiatric hospitalizations and managements. He had been
diagnosed as a case of bipolar mood disorder, schizophrenia, and
schizoaffective, or schizo-phreniform disorder during different periods and
treated with a series of mood stabilizers, like lithium and sodium valproate,
and also antipsychotics, and benzodiazepines. But during the past few years, he
was never completely symptom-free, in spite of relative compliance with the
prescriptions. During his recent admission, a dystonic reaction, as well,
appeared in the neck which was resistant against anticholinergic drug (Biperidene,
6 milligram per day) and decreasing the dosage of antipsychotic (Risperidone). So,
he had been referred to a consultant neurologist, who diagnosed medication
induced movement disorder, in addition to the formerly diagnosed primary
psychiatric disorder, and added Trihexyphenidyl (6-12 milligram per day,
instead of Biperidene) and Amantadine (100-200 milligram per day) to the
previous prescriptions. After two weeks of current treatment, due to
persistence of dystonic reaction, and also lack of suitable response of
psychiatric symptoms to prescribed medications, particularly their fluctuating
course, firm delusion of grandeur and impaired judgment in spite of the apparently
intellectual insight (IV/V) and normal cognitive & sensorium parameters,
another neurologic consultation had been asked for the patient. So, based on
the extensive bilateral and symmetrical calcifications in the basal ganglia,
thalamus, and cerebellum, in CT Scan and MRI, and ruling out Hyperparathyroidism
and Pseudo-Hypoparathyroidism , as major differential diagnostic
considerations in the evaluation for treatable causes of diffuse subcortical
calcifications , the primary diagnosis changed to Idiopathic Basal Ganglia
Calcification or Bilateral Striato-Pallido-Dentate Calcification (Fahr's
disease) and the patient transferred to
a neurologic facility for further investigation.

Discussion:

Medical
negligence is a ‘tort’, or ‘civil wrong’. It is a ‘wrong’ resulting from a doctor's
carelessness. Simply put, negligence means failing to do something that should
have been done as defined by current medical practice or doing something that a
physician with a duty to care for the patient should not have done (13).

Medical
error has been defined as the failure of a planned action to be completed as
intended (an error of execution), an unintended act (either of omission or
commission) or one that does not achieve its intended outcome, a deviation from
the process of care that may or may not cause harm to the patient, or the use
of a wrong plan to achieve an aim (an error of planning). Also, patient maltreatment
from medical mistake can occur at the individual or system level. Todays, the categorization
of faults is getting bigger to better classify avoidable causes and happenings
(14).

While about one percent of
hospital admissions result in an adversative event due to negligence, faults are probably much
more common, because these studies detect only errors that led to assessable adversative
events occurring soon after the mistakes
(14). Though independent review of doctors' management policies proposes
that decision-making could be enhanced in fourteen percent of admissions, many
of the profits would have late expressions (14). Even this amount may be
an underestimate (14). Medical faults are connected
with inexpert doctors and nurses, innovative techniques, complex or urgent care,
and extremes of age. Unfortunate communiqué, unreadable
handwriting, inappropriate documentation, insufficient nurse-to-patient proportions,
and alike named drugs are similarly identified to contribute to the problem (15).

The same problem exists as
well as regards the mental illnesses. For example, patients with ‘dissociative identity
disorder’ typically have past psychiatric histories that encompass three or
more separate mental
disorders and prior treatment failures (16). The skepticism of some physicians about
the legitimacy of ‘dissociative identity disorder’ may similarly increase its misdiagnosis
(16). As an additional example, female sexual dysfunction occasionally used to be identified
as female hysteria. Or else, food
allergies have been repeatedly misdiagnosed as anxiety
disorder . Likewise,
investigations have found that bipolar mood disorder has often been
misdiagnosed as major depressive disorder (16). While the
misdiagnosis of schizophrenia is as well a common
problem, there may be long delays before getting an accurate diagnosis (16). For
the same reason, the DSM- Five field trials have included ‘test-retest
reliability’, which involved different clinicians doing independent assessments
of the same patient - a new method for studding diagnostic trustworthiness (16). Anyway, back to
medical illnesses, according to a meta-analysis the five most usually
misdiagnosed diseases are cardiovascular disease, myocardial infarction,
infection, neoplasm and pulmonary emboli (17). On
the other hand, while doctor acquaintance with this data is variable (18), faults can
have an intensely negative emotional influence on the physicians who commit
them (19). As has been stated before, some
researchers believe that adversative consequences from medical mistakes generally
do not occur owing to isolated faults and essentially reflect system difficulties
(20). Such an idea is frequently
referred to as the ‘Swiss Cheese
Model’. This is the impression
that there are strata of safeguard for patient and clinicians to avoid errors
from happening. So, even if a physician or nurse makes an unimportant fault,
this is exposed before it really jeopardizes patient safety (for example, pharmacologist
checks the medications and corrects the slip). Such mechanisms include: Systematic safety methods,
practical modifications, training programs, and persistent specialized progress
courses (21).

On the other hand, medical and, particularly,
neurological illnesses happen repeatedly among patients with conversion
disorders. What is naturally seen in these co-morbid medical or neurological disorders
is an expansion of symptoms arising from the original biological lesion. Somatization
disorders, anxiety disorders and depressive disorders are particularly famous
for their relationship with conversion disorder. Meanwhile, studies of patients
admitted to a psychiatric hospital for conversion disorder, later, disclose that
25% to 50% have a clinically noteworthy mood disorder or schizophrenia. Similarly,
personality disorders, too, often accompany conversion disorder, principally
the passive-dependent type (9 to 40 percent of cases) and the histrionic type
(in 5 to 2
1 percent
of cases). The identification of conversion
disorder necessitates that clinicians find an obligatory and important link
between the source of the neurological symptoms and psychological dynamics, though
the symptoms should not result from the factitious disorder or malingering. No
doubt, one of the major difficulties in identifying conversion disorder is the problem
of absolutely exclusion a medical ailment. Parallel non-psychiatric medical
disorders are common in hospitalized patients with conversion disorder, and
evidence of a present or preceding neurological illness or a systemic disease
affecting the brain has been reported in 18% to 64 % of such patients. As has
been stated before, an estimated 25 to 50 percent of patients classified as
having conversion disorder eventually receive diagnoses of non-psychiatric
medical or neurological disorders that could have produced their prior
symptoms. Accordingly, a systematic neurological and medical workup is necessary
in all cases.

Neurological disorders
(e.g., dementia and other degenerative diseases), basal ganglia disease and
brain tumors should be considered in the differential diagnosis. For example,
weakness may be confused with multiple sclerosis, myasthenia gravis, acquired
myopathies or polymyositis. Similarly, optic neuritis can be misdiagnosed as conversion
disorder blindness. Other illnesses that may cause perplexing symptoms are
Creutzfeldt-Jakob disease, Guillain-Barre syndrome, early neurological
manifestations of acquired immunodeficiency syndrome (AIDS) and periodic
paralysis. While conversion disorder symptoms occur in schizophrenia,
depressive illnesses, and anxiety disorders, these other disorders are related
with their specific distinct symptoms that sooner or later make differential
diagnosis probable. In both factitious disorder and malingering, the symptoms
are under conscious, voluntary control (13). Because
somatoform disorders are positioned at the crossroad between somatic and mental
sicknesses, their differential diagnosis tends to be relatively all-encompassing.
However, there are numerous characteristics of these illnesses that can assist
the differential diagnosis. For example, the presentation of rather ambiguous
and multiple physical symptoms originating from several organ systems should usually
propose a somatoform disorder instead of a somatic ailment. As the number of somatic
symptoms rises (irrespective of whether they are pathologically clarified or inexplicable),
so does the probability that those persons will meet criteria for a psychiatric
illness, not a medical sickness. The following features can help in deciding
whether idiopathic somatic symptoms may have a psychiatric etiology:

1) The symptoms co-exist with important
psychiatric illnesses such as depression or panic disorder.

2) The symptoms strictly occur after
traumatic events.

3) The symptoms lead to
psychological "gratification" or "secondary gain."

5) The symptoms become inflexible,
join a conglomerate of other symptoms, and express such approaches as overuse
of medical facilities and disappointment with medical care.

The more of the abovementioned
features that are present, the more likely it is that symptoms can be categorized
as somatoform symptoms.

In general, differential diagnosis
from other psychiatric disorders is also difficult because many of the somatic
symptoms may be related to a psychiatric disorder such as depression (e.g.,
pain symptoms), anxiety (e.g.'' cardiorespiratory and gastrointestinal
symptoms), or even psychotic disorders (somatic delusions). Nevertheless, the existence
of a great level of idiopathic somatic symptoms has to be considered even if
they appear in the context of what is viewed as another primary disorder such
as depression or anxiety because they probably affect symptom strictness, management
outcome and level of incapacity (22).

Though no one has considered the total
expenses of misdiagnosis of medical illnesses, it is clear that, if the mistake
in diagnosis results in the deceases of patients, then the cost is tremendously
high. Consequently, it may be wise that the diagnosis of conversion disorder
not be seen as an absolute choice between biological vs. psychological
symptomatology. However, if the diagnosis of conversion disorder is assumed,
the clinician is recommended to prudently monitor current symptomatology to guarantee
discovery of a biological pathology.

Conclusion:

The
incidence of medical mistakes in primary care is not rare and the probability
of faults producing grave detriment is great, of which most could be taken as avoidable
or fixable, if management could be started almost immediately or at least not
too late. Sufficient attention to detailed process of development of patient’s
symptoms, their intensity, duration, priority and fluctuation, and, moreover,
vigilant medical checkup and thorough documentation of findings are helpful
issues for further lessening of medical and diagnostic faults. So, a rigorous work
and all-inclusive approach is compulsory for improvement of patient’s safety in
primary care clinics. This may contain enhanced educational core curriculums in
medical colleges, with an improved emphasis on psychological medicine, strengthening
the validity and reliability of available diagnostic criteria, constant post-graduate
training, and organizational amendments or revisions based on periodic
re-evaluations. Supplementary studies respecting the prevalence, etiology,
cultural or societal issues, student, faculty or facility related aspects,
curriculum efficiency, and objective self-monitoring mechanisms certainly will help
to reduce the problem.